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Blood Pressure Control: Addressing the Dominican Republic’s ‘silent killer’

May 17, 2021
by Elisabeth Reitman

Yulanka Castro-Dominguez, MD, has firsthand knowledge of the barriers to hypertension care. As a former medical student at Instituto Tecnológico de Santo Domingo (INTEC), Castro-Dominguez participated in an outreach program that involved managing patients in rural communities with elevated blood pressure or hypertension. Uncontrolled hypertension is the leading cause of cardiovascular disease worldwide — with Latin American and Caribbean countries experiencing the worst of the crisis.

Effective treatments such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are widely available. Still most patients are unaware of their condition. The EFRICARD II study indicated that 35 percent of adults in the Dominican Republic have hypertension. A study in the American Journal of Hypertension led by Castro-Dominguez, a clinical fellow, seeks to understand why one of the most common health conditions, hypertension, is undertreated in the Dominican Republic, particularly in rural areas with limited access to care.

Castro-Dominguez, Robert McNamara, MD, MHS, and other colleagues from International team of Educators Advancing Cardiovascular Health (ITEACH) have partnered with INTEC, the local Ministry of Health, and the Dominican Republic Society of Cardiology to evaluate strategies to improve hypertension care. In 2019 the team traveled to Baní, a town near the capital Santo Domingo, to collect data on patient awareness and hypertension management in the rural community and primary care clinics.

They interviewed 827 adults and found that 1 in 3 individuals with hypertension were unaware of their diagnosis. The survey participants who did know about their high blood pressure were more likely to be older women. They were also more likely to have insurance or had visited a primary care clinic within the past year. Likewise, men, underinsured patients, or those who had not visited a health care center were less likely to be aware of their condition. The research reinforces the need to screen at-risk populations for elevated blood pressure.

The study also uncovered another barrier to blood pressure control. Many patients, even those currently taking antihypertensives, were undertreated. Although the physicians recognized the problem of uncontrolled blood pressure, the rate of medication intensification was only two percent. The data suggest that primary care physicians in that community were reluctant to address the management of high blood pressure with their patients.

“Despite medication availability and affordability, and the majority of patients obtaining their antihypertensives from the primary care clinics, less than half of the patients were prescribed two or more antihypertensives,” the authors wrote.

This phenomenon has been recognized as clinical inertia (CI), defined as the failure of physicians to initiate or intensify antihypertensive therapy despite elevated blood pressure levels not at goal, and is a key factor sustaining the rates of suboptimal therapy. In this study clinical inertia rates were 65 percent. These high rates are not unique to the Dominican Republic. For example, studies show CI to be present in 60 percent of hypertensive visits in the United States, 58 percent of primary care visits in Spain, and up to 88 percent of visits in Brazil and Colombia.

A missed diagnosis of hypertension, lack of training or familiarity with the guidelines for hypertension management, and limited time for patient interactions in the clinic are some of the contributing factors. Clinicians in rural areas may be familiar with the guidelines, but they lacked the confidence to recommend treatment and instead deferred to a cardiologist or nephrologist.

The authors recommended establishing partnerships between the national primary care providers and cardiology and nephrology associations. In addition policy measures that prioritized optimal blood pressure control and regular performance feedback could improve health outcomes.

Submitted by Elisabeth Reitman on May 14, 2021